Generally, sun tans happen when cells called melanocytes oxidize the amino acid Tyrosine and create melanin, which protects you by dissipating over 99.9% of absorbed UV radiation, the proliferation of which makes your skin darker. Increased exposure to UV radiation from the sun induces production and induction of cytokines, growth factors, and neuropeptides, such as alpha-melanocyte-stimulating hormone which lead to increased melanin proliferation in the exposed skin. More sun exposure = faster, easier tan.

If you hide in your basement all winter then take a vacation to Florida in May, you burn to a crisp because all of these systems have down-regulated. Though your DNA has the code to make protections, exposure (or lack thereof) dictates that that part of the DNA is not being read to produce them. This is simply efficiency. Why run those reactions when there is no sun? Your body’s ultra-efficiency is often what gets you into trouble in unnatural environments (Suddenly sunny in January or swimming in a sea of Frappuccino).

Gradual increased exposure to  the sun will cause these systems to “up-regulate” and ramp up the systems that produce melanin to protect you without burning you to a crisp. Environmental exposure dictates up or down-regulation of what is “read” from the genome.  How efficiently an organism deals with epigenetic changes dictates how well it evolves genetically.

If a tree with a tap root that reaches a deep underground stream is faced with drought and loss of the stream what does it do?  It grows fine feeder roots right under the soil surface to collect as much rain water as it can right from the soil surface as soon as it falls from the sky.  Environmental exposure dictates genetic behavior.

Heat-shock protein expression is absent in the antarctic fish (big surprise).

Of course this is true for all of your metabolic enzymes. We have systems / pathways in place to utilize many different fuel sources, but the modern Western diet (environment) is glucose-based, so fat-burning pathways go away. Hitting the gym does not bring them back. An insulin-free diet does.

We eat glucose non-stop, often in enough volume to trigger the release of insulin: Toast or yogurt for breakfast, bagel for mid-morning snack, sandwich for lunch, pasta for dinner, something sweet before bed…day after day for decades. When glucose / insulin is omnipresent, your fat-burning pathways down-regulate. This is simply efficiency. Why run those reactions when you are in perpetual glycolysis?

When you finally decide to eat right and go to the gym, you don’t lose any fat because you ‘burn’ glucose preferentially. If you happen to burn up your stored sugar, your liver will tear down your skeletal muscle (proteolysis) and turn it into sugar (trans-amination) and protect your fat, which is meant to save your life.

Sadly, when you do burn up your stored sugar, it is actually stored as a compound with lots of water, which is heavy.  So loss of that water + sugar gives the illusion of having lost a lot of weight, which comes right back as soon as you refill those glycogen stores.  This leads to heartbreak that causes many to just give up the idea of diet & exercise.

If exposure dictates genetic behavior, then you will metabolize fats and cholesterol more efficiently when you eat more fats and cholesterol and up-regulate those metabolic pathways-this must be done in the absence of insulin. But be careful.  If you have been in the Glucose basement for a long winter, do not rush into the Florida bacon. Gradually move from lean meats to fatty.   Years ago when I first read Dr. Atkins book, he explained that everyone is afraid of meat and cholesterol but your cholesterol actually goes down on his diet-but he wouldn’t explain why! Epigenetics was not a hot topic in the early 70s.

Once those adipose-burning enzymes are up and running, you are called “fat-adapted”; You burn fat preferentially instead of burning glucose preferentially.  Ascertaining what fuel you are burning can be done via Respiratory Quotient, just remember that your muscle shows up as glucose once trans-aminated.

If you then frequently burn fat as ketones via extremely low glucose load, you can become “keto-adapted”. This is why it takes some people 3 days to become ketotic and some people 3 weeks: enzyme up-regulation. And then the fat melts away sometimes too fast. You don’t have to live this way, but if you need to swing the pendulum, you can do this for months or years.

And this is why genetic twins can have vastly different metabolic behavior-same genes, different reading of those genes.

This is done by diet, not exercise, but exercise will help all of this along tremendously.

Inversely, the Inuit, who only ate fish and blubber and got all of their carbs & phyto-nutrients from lichens they scraped from rocks, most-likely had severely down-regulated glucose metabolism enzymes. Some of the people in the “Paleo” crowd do, too.  They spend so much time metabolizing fats that they need to schedule “Glucose overfeeds” so they don’t down-regulate those enzymes. Take as long of a pause as you need to come up with whatever that says about modern society. It’s ridiculous but at least they understand the system.

So when someone like Mark Sisson writes a book with the strapline: “Reprogram Your Genes for Effortless Weight Loss, Vibrant Health, and Boundless Energy” this is what he is talking about, though it probably looks like pseudoscience to the cynical diet-book recidivist. I refer to this concept again & again while talking metabolism.

“I’m not overweight and I run a lot, so I am not at risk of diet-induced metabolic disorder because I balance my calories with activity.”

This is incorrect. Obesity is a marker for metabolic dysfunction, not the end result.

In fact being “Skinny-fat” can be more dangerous than carrying extra pounds. What is skinny-fat? In short- not enough meat on the bone.

You must maintain muscle volume to carry out basal metabolic function. You know how your doctor looks at your cholesterol and says, “Well, your ‘bad’ cholesterol isn’t high but your ‘good’ cholesterol is still too low,” and you say, “But if ‘good’ cholesterol is for removing ‘bad’ cholesterol which I don’t have, why do I need more?” And the Dr. says “Just shut up and fix it! I’m a doctor, not a professor!” Skeletal muscle is a similar circumstance.

Oh crap. What? Ketoacidosis? Let’s see if this is associated with regular dietary Ketosis.

I was writing this as an entry to my diet journal, but as usual, it became long and involved enough to become its own post.

On a lark, I decided to try the trendy butter-in-the-coffee thing.  I like Dave Asprey. He’s the “Bulletproof Coffee” guy.  Originally, I had an immediate disdain for him because I loathe the word “hacking” used in any context that doesn’t involve Oliver Wendell Jones. “Bio-hack” especially. No, I don’t want to “hack my sleep”, thank you. But some dudes I respect like him, so I have to listen to him, though I really have to review his science sources. I find a lot of it far-fetched or over-reaching in claims. If minor changes made such obvious beneficial differences, we would all be doing it. I think a lot of placebo is involved. That or you have to buy into his whole lifestyle, otherwise you make each individual effort null and void.

But I reserve judgement, I promise.

I like his bulletproof podcast and his interviewing technique but ultimately I find his diet plan too restrictive and diminishing of my quality of life.  I appreciate his research and take it to heart and apply what I think is reasonable under the umbrella of Mark Sisson’s 80/20 rule.

I keep in mind that much of his advice ties into some product that he sells. I don’t think he’s a huckster. I believe him and Mark Sisson when they say they want to make products they believe in available to others. But my goal is to show people that they can get healthy without spending money. No Weight Watchers, No DVD sets, no boxes of supplements, no mass-produced Gluten-free and no mass-produced “paleo” analogues of “normal” food, no Atkins Brand chocolate cake.  A gym membership is strictly optional. I just want you to invest in higher-quality meat and vegetables and put a little time into some Youtube videos instead of your regular TV mush. And ain’t nothing cheaper than intermittent fasting, which is very healthy for you.

In the long run you will save money- not only on fitness products and food, but how much will diabetes or cancer or a heart attack cost you or your loved ones once you’re gone? Once you are lean and feeling good and want to start advancing, Then feel free to dabble in Dave’s sub-atomic particle activated carbon, or Mark Sisson’s multi-vitamin supplements, or Sally Fallon’s $40 cod liver oil or a membership to a High Intensity Training gym or Dave’s super-computer systems that help you build a six-pack through guided imagery. I’m all for it if you’ve got the money, but insist that it is not required for health.

Based on an old Tibetan tradition of putting Yak butter into tea,  Dave Asprey wants you to drink a lot of coffee (mold-free coffee, and of course only his coffee is mold-free)  and add cultured, grass-fed butter and MCT (Medium-Chain Triglyceride) oil. I’ll let you investigate his whole story and reasoning on your own if you are interested. There is a big debate out there as to whether you should use MCT oil or the whole food from which it comes, coconut oil. Dave of course sells “Brain Octane” oil, which is a super MCT oil that was probably “hacked” (rolleyes). This is all supposed to give you unbelievable energy and brain clarity.

Of course you will find a million websites claiming this is all B.S. But not many of them are talking real science.  There are claims that Dave’s experience can be chalked up to his Thyroid medication, or whatever. And of course he’s selling stuff, which bothers people. But to research this you really have to look at the science of coffee polyphenols and the science of how grass-fed butter makes them more bioavailable.  Dave usually has hundreds of scientific papers sourced for his claims. To have one dipshit throw it all away because, “well, you know…Tibetans and Sherpas have altered mitochondria from living at high altitudes, so this is all bunk” is actually a little unintellectual, though it’s what some people want to hear. You have to refute all of his sources, not him personally.

Do intense research and personal experiments, especially before you give people money but before you dismiss out of hand. Finding people ranting in ignorance is the easiest thing in the world.  I have so many friends who have never read a book yet have all of the answers. Misguided vocal minorities are shaping your world every day, so take this seriously.

I’m on the grass-fed butter bandwagon because of Sally Fallon  and have been looking for a way to get more of it into my diet. I just happened to have a jar of coconut oil which is a normal grocery store item (actually my mom gave it to me).  So what the heck. Let’s try it. MCT /Coconut oil is supposedly very ketogenic. I don’t know why I would want ketosis of dietary fats. I want the ketosis to use my spare tire & belly as fuel, not exogenous calories. But maybe it gives that metabolic pathway a boost. In regards to brain/mind clarity, I do know that the brain loves ketones.

When we were young in our relationship, my wife tried a culinary experiment.  We were out of cream for coffee but we had butter and she reasoned, “Well, butter is dairy. How bad could it be?”
Pretty bad, let me tell you.  That one still comes up from time to time when discussing our bad food decisions.  Apparently the trick is to use a blender, not a spoon. You need emulsion.

Most importantly!! When you put hot liquids into a blender, they pressurize and blow the heck up. You must use something big like a Vitamix. I’ve never seen this mentioned in “Bulletproof” coffee discussions, but luckily, I’ve already blown up hot soup in the past and happen to have a Vitamix.

The taste result: Not bad at all. I enjoy coffee purely as a gastronomic experience and will not tolerate a change in flavor at all. I don’t drink coffee as an “energy boost” as my body is not sensitive enough to sense it. I have made this coffee a few times now and decided that I don’t like the coconut oil in it. If I find a way to ingest a tablespoon of that right before drinking the coffee I’m fine. I also add a little heavy cream after blending.

The physiological response: I honestly had the most energetic day of this year. I am not kidding.  I shoveled the driveway, went to the gym and did a full run on the elliptical and was ready to do it all over again.  So I did a full circuit of weight machines which I am normally very tepid with owing to the myriad joint injuries I’m currently suffering. Then I went swimming for half an hour and left the gym feeling great. This morning, my circulating ketone level is pegged and the scale is two pounds lighter than yesterday (possibly water weight from the intense workout depleted hydrated glycogen).

Now, I didn’t  feel energized during this. I wasn’t jittery. It’s just that nothing was fatiguing me. Normally I do a little work at the gym and I’m ready to hit the sauna. But I was flying. I wasn’t  expecting a result from the coffee and as I mentioned, I didn’t feel energized.  So I don’t think it was psychosomatic but you know what? Placebo is a very powerful drug. I don’t care if that’s it. Somehow I doubt it.  Only prolonged experimentation with this will tell me.

I don’t know if you could experience this as I did because I am already ketotic and feeling the perceived energy boost from the fact that insulin is not making me sluggish, stimulating anabolic hormonal pathways and blocking my leptin signalling. If you are currently metabolically tuned to burn carbs preferentially and insulin is ruling your system, I’m guessing you won’t have the results I had. But who knows. Let me know if you do. I’ll be making notes in the weight-loss journal.

In a 2012 Talk entitled Fitness, Health, and Liberty at the 21Convention, Doug McGuff, an Emergency Room MD from South Carolina explains exactly what is already irrevocably around your neck and only going to tighten by giving a history of our healthcare system over the past 100 years. There is something in it for the liberals because he’s going to beat up on the Big Business. There is something in it for the conservatives because he is going to indict the Government. He will undeniably show how everyone involved, including 100 years-worth of stupid voters are at fault for this mess and why you really only have one job now which is to Stay out of the belly of this beast.

Which I have painstakingly transcribed for you for review of and comment upon. If you pinch the text, please give me transcription credit. But this labor is my gift to the world.

If you have neither time to read this nor watch it, I suggest making an MP3 out of it and listening during a commute, mowing the lawn, running on a tread mill, etc. I have very few friends who stand to learn nothing from this lecture. Doug will:

• Demonstrate well-meaning, community-intended ideas that came with criminal fiscal irresponsibility.
• Explain why your inner city emergency rooms look like 19th Century Flop Houses.
• Show why everything medical you do is at an out-patient center
• Parse out details such as: HIPAA is not for your confidentiality or assurance of consistent records-it hides the collectivism trumping your personal rights
• Support my idea that we should just kill all the Baby Boomers now.

~~begin transcript~~

Normally I talk about exercise and diet but there’s not anything that I can tell you about exercise that you are going to remember that Skyler did not cover beautifully yesterday in his lecture so if you’re watching this on video, go watch Skyler’s Talk and you will have everything you need to know about exercise in that talk.  Likewise, with regard to diet, there is nothing that I could tell you today that you are going to remember that wasn’t beautifully covered by Jolly or Dave Asprey in their talks today. So I would reference those for you. So instead of like in 2010 me telling you the how of the Paleo diet and the how of exercise I wanna tell you why.  And I wanna do that from a very unique perspective and that perspective is: 23 years practicing in the epicenter of the implosion of the American healthcare system.

If you care about your liberty and preserving it, you need to care about your health. Now, everyone that’s sitting on an aisle seat on this side of the room, please raise your hand. OK, everyone look around for those of you that are younger than 35-years-old in this room, statistically speaking, this is the number of you that will be dead before you are 35. Keep your hands up. Everyone on this side of the room please raise your hand.   That is the number of people, statistically speaking that is going to have a serious life-threatening health condition or injury before they reach age 35. That’s why this is important that is why I want to talk to you about fitness, health and liberty: preserving personal freedom by staying out of the Belly of the Beast.

Now one thing that I want to make reference to as we go through all this is remember that every step of the way in this story that I am going to tell you. When we made a mistake or did something wrong, we never go back on that mistake. This is true of individuals but it is particularly true of bureaucracies and government. If they make a mistake that did not work out, well they never go back on it. They always double down and do even more of it.

So, medical care.  What is it? What should it be vs. what it is. What medical care should be, is a free market exchange; a fiduciary relationship between the provider of a service and a consumer. The moment that you engage me as a physician, I should have a fiduciary relationship to you to take your best interest at heart. But what is it actually today? What it is, is a 3rd party relationship where the provider is coerced to place the needs of a collective over the needs of an individual. Now in a proper circumstance when you engage me as a physician we would be discussing both the price and the extent of the care that would provided up front.

As it stands nowadays if a patient’s coming through the E.R. even with something as simple as a laceration and they ask me, “Doc, what’s this going to cost me?” I have no idea what to tell the patient. If you get admitted to a hospital you have no real means of negotiating what your extent of treatment is going to be. In most cases, the extent of what is provided to you would be way beyond what you would normally negotiate under a correct provider / recipient relationship. The other thing that happens is: instead of you getting to decide what you want and what you don’t want, whether you want a statin or not want a statin, you kind of get a take-it-or-leave-it attitude because the system is now protocol-driven.  If you don’t fit in to the protocol or accept the protocol…you know, there is no negotiation. It’s all or nothing.

So who’s to blame for all this mess? Doctors.

This is an important point for all of you. Whenever anything is screwed up in your life I want you to say four words: It is all my fault.  Five words?  It’s all my fault. Assume responsibility for everything that’s screwed up in your life. Doctors did this to ourselves. The doctors that did it did it with short-term gain in mind, and they probably knew that the consequences of this would not be born in their lifetime but in the life time of future physicians and future patients. But they sought the help of the Government for short term gain and they set in motion the long term unintended consequences that has resulted in our ultimate enslavement.  So what’d they do?

Anyone ever heard of Blue Cross and Blue Shield?  This came about in the Great Depression. Now before the onslaught of everything that we currently have, a lot of physicians provided a very large mass of charity care and during the Great Depression- a calamitous economic event triggered by Government regulation – not many patients were being paid for their services. This is where you heard about doctors being paid in chickens and eggs and milk and what not because this is all that people had to exchange with. The medium of exchange had gone down to that. That they devised was an insurance system whereby they were guaranteed to receive a payment for their services but they bastardized what insurance actually is. What insurance should be is you pay a premium along with a lot of other people that goes into a kitty that will pay you should you encounter some catastrophic unforeseen event, but the insurance structure that they made was something to pay for everything: routine office visits, medications, screening tests, the whole nine yards. Come to the office with an ear ache or a sore throat, it was under the umbrella of this insurance that you paid premiums for.

Furthermore, they sought a tax-exempt status. What they wanted to happen was people that were buying their insurance plan was for them to be buying that with pre-tax dollars. Normally when you buy insurance, when you buy automobile insurance…when you buy life insurance, you buy it with post-tax dollars. That means if you made $100 the government takes $40 and leaves you with $60 and you buy your premiums with that. When something is allowed on a pre-tax basis, you get to buy it with the $100 you originally made. So in essence, you’re buying it at a 40% discount. Well the Government said “OK, we’ll do that but what we want in exchange for that is a community rating.”  Does anyone know what a community rating is? Basically what that says is: anyone within a geographic catchment area pays the same premium regardless of their pre-existing health status.  So that’s created layers of what are called moral hazards.

So what’s Moral Hazard? Well, Moral Hazard just has to do with what your behavior is under different circumstances. Let’s string a tight rope on the top floor of this building across the street to the other building. Well, Moral Hazard is the difference in the way you behave on that tight rope when there’s a safety net eight feet below you versus when there isn’t. So people’s behavior was changed by the fact that they were covered for everything. The consequences of not washing your hands or eating something that sat out for too long were now much smaller. You didn’t have to pay if you got sick even for the most minor of illnesses. More importantly, you felt as if you were going to be taken care of even if even got a more major illness that ocurred as a result of your behavior over time.

So this was great for the doctors at the beginning of the medical Ponzi scheme. But not so great for those of us down the line. So- what happens next? Well remember this is occurring in a medical market where different providers are competing within that market. So, commercial insurers tried to compete. People that aren’t Blue Cross / Blue Shield that don’t have the pre-tax benefit- they have a lack of tax-exempt status, they’re forced to compete by offering a similar product. So what happens then is the concept of third-party payment for medical services becomes entrenched. This essentially becomes pre-paid medical care. This makes comparison shopping near-impossible because you’re not comparing price as you would in an open free market – its premiums and it creates another moral hazard that’s called Friedman’s Quadrants. And it refers to Milton Friedman.

And I wanted to have a white board up here to draw it for you but to spare us all the rigmarole of trying to get that thing up here let’s just divide this screen into quadrants. And on one side what we’re going to have is your money and then below is going to be someone else’s money. That’s the Y axis. So on the Y axis, we’re going to have your money and someone else’s money. On the X axis, we’re going to have yourself and someone else. So, when a person spends their money on themselves they’re going to worry very much about the price and they’re going to worry about the quality of what’s supplied. That is where the most conservative economic calculations occurs. Now if you’re going to spend your money one someone else, you’re still very concerned about price but you’re not quite so concerned about quality. You’re buying a birthday present for someone and you’re like, “Eh, I think they’ll like it. Maybe they’ll hate it. I will never know so I don’t really care that much.”

So down in this quadrant you’re going to spend someone else’s money on yourself. And that’s kind of where we’re starting off with this. There, you don’t care so much about price but you care about quality and you want to make darned sure that you get the quality you want but you don’t really care what it costs someone else to provide you with what you want. This is sort of the equivalent of being a welfare Medicaid recipient. And in the last quadrant is the worst kind of spending you can do and that is to spend someone else’s money on someone else. When you’re in that quadrant and you are spending you don’t care about the price and you don’t care about the quality. And when you create a third party payer medical system, that’s what you have.

People are not buying their healthcare in a direct transaction. Healthcare is bought with premiums that you have no idea what the cost is and you don’t care. How many of you people are employed and covered under employer insurance? Do you know how much it costs you every month? We got one guy? Do you know how much comes out of your paycheck? Dollars and cents?

Audience member: “$92…126?”

It’s variable but the number of employees that actually know what’s being taken out of their paycheck and whether those are pre or post tax dollars and all sorts of … If you go to an ER do you know how much you’re going to pay?

Audience member: “Just my deductible, 100 bucks”

So you pay a hundred dollars and you’re covered 100%? You don’t have an 80/20 or anything like that? So most people – they don’t know how much is being taken out and they don’t know what’s it’s going to cost when they show up for care. So this creates another moral hazard because you’re down in this quadrant- you don’t care about price, you don’t care about quality.

So, the situation was made worse by the 1942 Stabilization act– we’re in the middle of WWII. A lot of America’s men in the work force are off fighting war. And the thing you’ve got to realize about labor is like anything that’s bought and sold, or anything that’s scarce it has a price. So wages could potentially go up during this time of economic hardship which could put a real strain on employers so there’s a lot of political pressure to freeze wages and that’s what they did. But all of a sudden, employers were hamstrung for competing for very limited labor supply. So what happened then is the government allowed employers to compete for scarce labor by offering benefits such as their health insurance to not be considered in the wages act. What happens then…is these are pre-tax dollars and they’re not taxed and that amplifies this whole effect. So remember price controls will always create shortages. They applied price controls on wages which created a shortage a shortage of labor. So they had to find an end-around and their end-around was to offer benefits or things that were not counted as wages under the act.

Then what happens? The IRS gets involved. In 1943, they made certain that any premiums paid by employees in a group plan were exempt from federal income tax and they decreed that health insurance premiums are now legitimate cost of doing business and they can be deducted from the employer’s taxable income, too. So this has collectivized things both on the employee and the employer side. So collectivism is incentivized. So these tax incentives were available to anyone that got their healthcare collectively through employers but it was not applied to individuals who individually bought their insurance policies for themselves who wanted to stay independent, who wanted to preserve as much as possible that relationship between themselves and their doctors so they were financially punished for trying to remain independent.

So what are the logical consequences? Employees become unaware of the cost of what they’re seeking. And because it’s bought with pre-tax dollars dollars and there is no apples to apples comparison of what that really means in terms of your salary. Especially since taxation rates are gradated. The first money that you make is taxed at a lower rate than the middle money that you make which is taxed at a different rate that the top-end money that you make. So it makes it very hard to form any economic calculations. Employers insure the group without any concern for the given individual’s circumstance so you may have very peculiar or particular healthcare needs based on pre-existing conditions, congenital problems…but it doesn’t matter. They’re insuring the collective- the whole. That’s their concern. There is no concern for the individual anymore and worst of all it feels like an entitlement. It feels like something that just comes along with being employed. When I’m employed, I have “benefits”. I’m covered for my health insurance. And it engenders a buffet mentality. You’ve paid in a certain amount for your premium and now when you go to a buffet there’s a lot of food in front of you and you have to pay $14 to go the buffet are you really going to stick to your diet or are you going to get your money’s worth by gorging yourself? That’s the problem with a buffet. And that’s the problem with the logical consequences of making this sort of system.

So then what happens next? Well, prior to 1965, there’s always been indigent care. There’s always been a need to care the poor or the elderly who became destitute, either because of their actions or innocent of their actions. And prior to 1965 this was done on a charity basis by almost every doctor in the country. There were entire charity hospitals for providing care to the indigent. If it wasn’t a charity hospital almost every hospital in this country had a charity wing. Which is separate from the rest of the hospital where charity care was provided to those who needed it. But what Medicare and Medicaid wanted to do is they promised not to control medicine…”We just want to pay the bill.” But the real point of the thing was not just to take care of the elderly and the poor, the point was to spare them the humiliation of means testing. To actually spare them the humiliation of having to put their hand out and say, “I need help.” But that is the difference between a charitable act and an act of force. Putting your hand out and saying, “Can you please help me.” vs. putting a gun to someone and saying, “Give me this”.

The other thing that is did and the insurance companies rather liked this is it removed anyone over 65 from the insurance pool. So you’re a commercial insurance companies- you just took the totality of your highest risk covered lives out of your bailiwick and you don’t have to worry about it anymore. The public sector is going to take of that so your profit margins just went through the roof and it shifts the cost on the government which is you the tax-payer. Oops.

So, what are the logical consequences of that? Remember, at every step of this process when we screw up we don’t go “oops” and go back, we go, “oops” and double down. So what’s the Oops?

Baby Boomers. Holy Crap! The hugest population explosion in the history of our country was going to come to fruition under this act. So what happened is- you’re promising care to a huge number or people who paid in when it was extraordinarily cheap but you’ve created a system where the cost of providing that care has to go up exponentially. So now you have a situation where if you’re going to keep this thing propped up from one election to the next, which is very important because this is also a demographic that votes and votes with fierce self-interest very much in mind. If you doubt if the baby boom generation has screwed you young guys -they know that they were at the beginning of a Ponzi scheme. And they were more than happy to pass that debt off onto you. You’re going to pay for this with money you’re not going to earn until you are 50 years old.

So how do we keep propping this up from one election to the other? Well we have to control costs. Well we do that by limiting treatment to what is considered appropriate or medically necessary and we try to limit payment to doctors. The other thing it did is it outlawed any supplemental payment form the patient to the doctor. So they start limiting how much they pay doctors- doctors don’t want to see patients anymore. Well a lot of people that were forced into Medicare said “Eh, I’m well-to-do. I’ve got plenty of money, Doc. I’ll pay you the difference between what you get from an insurer- someone that pays out of pocket- I’ll pay you the difference between what Medicare pays you and what you would have gotten.”

Well guess what? The government will not allow the doctor to do that if he participates in Medicare. So if you take that kind of money from someone you are subject to a federal crime that is going to send you to jail and you’re going to be subject to fines which under federal law have treble damages which means that whatever they decide to fine you- you owe 3x that amount. If someone in your office finds out- there’s something called ‘qui-tam’ which is a whistle-blower statute that says not only do you pay treble damages, the person that rat-finked on you, whose payroll you meet, gets treble reward too. So you end up paying six times the fine that is levied against you. So this has huge teeth. So what’s the next thing that happened? That wasn’t enough. It didn’t stop it.

Next thing was DRGs – Diagnosis-Related Groups. This came about in 1982. And it was courtesy of a couple academics by the name of Robert Fetter and John Thompson who were public health and epidemiology experts from Yale. And they came up with this system of paying doctors in what are called diagnosis-related groups. And what they did was they standardized different diagnosis through this giant manual called the ICD which is I can’t remember what is stands for- The International Compendium of Diseases or something of that nature (International Classification of diseases ~Jimm), but what it boils down to is that if you get admitted to the hospital and you have a certain primary diagnosis you get a certain number of hospitalization – a fixed amount they are going to pay for and that’s it. And it’s on the lowest possible end of what you can be paid from something of that complexity. Well what that is, is essentially, is a price control on in-patient medical care. Remember any time you apply price controls you get shortages. This created a shortage of in-patient hospital beds because hospitals could not admit that many people into the hospital and incur those kinds of losses. They had to back off on the number of people they were admitting – make the hospital smaller, have fewer beds because they can’t take that many losses under this payment system. This is why if you go back to your home towns and you look at a local community hospital what you’ll see is this dilapidated, old ugly building that has maybe 134 beds in it. But right next door to it, you’ll see a palatial, beautiful, bigger-than-the-hospital outpatient surgery center or an outpatient radiology center or a blood collection/transfusion center. Because they’re trying to divert their activities into the out-patient setting where these price controls did not exist.

The other thing that happened is it triggered cost-shifting. If you’re going to lose that money on the in-patient side of medicine, you’re going to shift that cost to other areas. This is where you get your $200 Aspirin in the E.R. We’re trying to make up for the constraints there. You push down on a balloon on one area, it’s got to expand in another. So they’re trying to preserve market signaling in the presence of something that distorts it. So that’s going on.

Then next thing that happens is what has affected my life so immensely. 1986 – Signed into law by one of our most conservative Republican presidents in modern history – EMTALA stands for…it was part of COBRA: Congressional Omnibus Reconciliation Act of 1986. This was a sub-component of COBRA called EMTALA: Emergency Medical Treatment and Active Labor Act of 1986. And what was happening is, when you go to do a residency at a public hospital or a county hospital -residency: you’re going to specialize in internal medicine, family practice, surgery, neurosurgery, orthopedics; ophthalmology-residencies are paid for with CMS funds- with funds from the Center for Medicare Services. So that created an obligation for hospitals that had residencies because they were receiving funds and tax advantages to take care of indigent care. So in 1985, if you were a private hospital and you have an indigent person show up with a medical condition, you just tell the ambulance to do a U-turn. You go to the public hospital. They receive funds for this kind of care. Go get your care there. And that’s what happened. And that’s how the indigent paid for their medical care was by essentially being the patient for medical residents. But public funds were going to those hospitals. It was considered fair but all of a sudden the public hospitals under the effects of the DRGs were getting all these non-paying patients coming in and suffering even further loss than the constraints of the DRGs. You had non-paying people. So they started to scream and yell that this was dumping. “You’re dumping your undesirable patients on us simply because we’re good guys.” So we signed this into law and what it does now is it requires any emergency department, any E.R. to treat anyone who presents within the hospital property or 250 yards of the E.R. regardless of their ability to pay. What that also means is regardless of their intention to pay.

How quick did you think it took people to figure out how to game this system? You want to talk about viral spread of an idea? It happened overnight. The public hospitals…emptied out. They were like, “What happened? Our waiting room used to be jam-packed” and everyone was going to the more desirable hospitals because they were given a political mandate by force that they could go get that care for free. And it’s an un-funded mandate with severe penalties. There is no mechanism to pay an emergency physician for seeing this.

So what this did is it made emergency rooms the de facto national health plan for the uninsured. State and local governments abdicated all responsibility for charity care and based on statistics, that were done around 2000, they said the average Emergency physician is providing $138,000 a year in uncompensated care, I myself- when I calculate- provide approximately $350,000 in uncompensated care based on Medicare payment rates. Which as we’ve already discussed are price-controlled. So that’s the low end of the spectrum assuming that applying that, I provide about $350,0000 in uncompensated care. About 23-30%, depending on the quarter that you look at, of the patients that I see pay me anything. So this resulted in further cost-shifting just to survive. This is where you get your $200 Aspirin in the ER. And the thing is- it’s the law that was intended to help the poor hurt them the worst.

There was a massive influx of non-paying patients and that contributed to ER overcrowding. And most people when they think of an over-crowded ER, blame this scenario for the overcrowding. But I’m here to tell you it’s maybe 15% of it. Where the real overcrowding in the ER comes from is the lack of inpatient beds because of the price-controls applied by DRGs. Because the people coming into the ER are sick. There’s a lot of minor stuff that comes through and you’re always kind of turning that wheel but there is no shortage of critically ill people coming through the ER. And you have to get them. You have to stabilize them. Get them treated. Get them ready to be admitted to the hospital but guess what? There’s nowhere for them to go. There no bed upstairs. So they end up boarding in the ER. So the size of your ERs bed capacity starts to shrink. So then instead of having 20 beds to move a big back log of patients in the waiting room through, you now have ten. And in a few more hours, you’ve got five. And then you’re really hosed. So the real problem with the over-crowding is not just the massive influx of people coming in the front door, you’ve got nowhere to send them upstairs because of in-patient price controls.

The other thing that happens is the on-call doctors- the people you need for back-up- the orthopedist for the broken hip, the neurosurgeon for the gunshot wound to the head- they stop taking call. And they stop taking call because they know that when they get a call from the ER at 3 in the morning there is a 70% chance that they’re going to get up, go out of bed, take the risk of taking care this patient for no compensation, finish up that surgery and go to an office that’s backed up. So they stop taking call. So we’ve got no back up for a lot of different specialties.

Next thing that happens: 1996 – HIPAA. That stands for Health Insurance Portability and Accountability Act of 1996. And basically what this law was to do was to give Government enforcement of the Hippocratic Oath, part of which is to say: Anything that happens between the doctor and his patient remains confidential. And the reason for this is when you collectivize medicine , the ability to keep it confidential because you’re serving the collective and not the individual becomes compromised.

The other thing that was happening was the government was already planning to mandate – remember this is 1996 the internet boom was going, computers are going to solve every problem on the face of the Earth. So there is this huge governmental push for electronic medical records and they worried about sensitive personal information being stolen so they impose imposed huge penalties if you even inadvertently violated anyone’s confidentiality. I cannot practice medicine on a day by day basis without violating this law every time. If someone comes from a drug house or a rave party unconscious, whoever’s with him, you know, some kid with pink hair and a bone in his nose- I gotta drag this kid in that’s remotely their friend and say, “Here’s the circumstance with this guy -he’s dying right in front of my eyes do you know what he did?” Under this law, that’s a violation. But I have to do it every day just in order to be able to practice. It’s impossible to comply with.

But if you have something called a “compliance program”, if you hire someone to serve basically as a government rat-fink within your own organization, then if you have a slip-up, then you’ve at least demonstrated that is an honest slip up and the penalties are less severe. You have to incur essentially a full-time equivalent of hiring a person on board to make sure that you’re being HIPAA-compliant. And every time you go into your doctor’s office- the first thing they give you is this big long sheet of paper about your privacy rights that you have to sign. Anyone that’s been to the doctor’s office recently knows what I’m talking about. But this was greasing the path for the electronic medical records which I now have to deal with. This all combined, signals the death of private practice.

Overhead burden from Medicare Medicaid, private insurers, HIPAA, it eats up all of your profit margins. In the past four years, 80% of family practice doctors in my community paid themselves no salary. Of the ones that did, they paid their nurses and mid-level providers more money than they were able to net out of their practice. As a consequence, these people were bought up by hospitals who had the scale to deal with the regulatory burden. It’s wasn’t like they were brought in by a hostile take over. These people begged the hospitals to be employees because they couldn’t make it otherwise. That’s what happened. So now what you have is medicine is collectivized both on the provider and the recipient side. Control is easier. You have control of both sides of the equation from the government standpoint.

Even if this was an unintended consequence, you couldn’t have devised a more diabolical system for getting complete control.

Ultimately this created a Hospitalist movement. If you get sick in the old days, your doctor would see you in the office, say “You’re really sick, you need to be in the hospital.” He’d do a complete history, physical exam, write admission orders, send you over to the hospital, you go upstairs and he’d see you. From his office-he’d either see you immediately if it’s urgent or see you later in the evening after office hours. But your doctor who knew you intimately would take care of you in the hospital. No more. All in-patient care is shifted to hospital employees which are Hospitalist. They provide the in-patient care when the patient comes into the hospital. And this happens because the hospital practitioners that became hospital employees are now under sever scrutiny to be productive within the office and if they have to come and provide in-patient care mess up their schedule, they’re productivity falls and they get in trouble for it.

There’s also a refusal to take call because EMTALA increases their exposure to making their bottom line look bad and make them look bad and the hospital and the hospital has no conception of calculating the economic value of doing something that the government has mandated that you do. So the hospital’s been hired to provide in-patient care and these are excellent physicians. But they’re excellent physicians who’re under enormous pressure to practice for the collective rather than the individual. And to their credit what they’ve done because these are doctors – very smart people – is they have become very creative at kind of subverting the system and making it work but what happens is the Government constantly changes the rules of what they’ll pay for and what they won’t pay for so it’s always a moving goalpost. So in order to the help the Hospitalists, the hospitals now hire case managers. Case managers are usually nurses who have the good sense to get out of clinical care or social workers. And they have this big manual from the government about what they will and will and what they won’t pay for and what the diagnostic criteria for being admitted into the hospital are. And they help the Hospitalists figure out what they can and cannot do. Now make no mistake, if something doesn’t fit this template, they’re not saying you can’t admit the patient to the hospital. They can and we do all the time. They’re just saying “We’re not going to pay for it.” And when the hospital is under this much financial pressure, there’s very huge pressure to predicate your admissions to the hospital based on what’s allowed.

So finally, the Patient Portability and Affordability Care Act – Obamacare.

This was signed into law on March 23^rd, 2010. I watched it while waiting in a neurologist’s office for four hours to be seen. The reason I was in the neurologist’s office is that I got a weird neuropathy. I thought it was a pinched nerve in my neck. Maybe from working out. But my intrinsic hand muscles atrophied to the point where I could no longer pinch or turn a key. One day I had a patient that went into respiratory arrest. I had to intubate them. I used a laryngoscope to expose their vocal cords and the endotracheal tube- the plastic tube we put down your windpipe- I couldn’t hold onto it as I was passing it through. And I was like, “Oh, crap-I gotta figure this out.” So I was waiting to have a nerve conduction velocity done. As it turns out I had something called Cubital Tunnel Syndrome. We were mandated to have electronic medical records or face severe financial penalties in terms of what Medicare would pay you. So, huge pressure from the hospital – we went to instead of voice-dictation that was transcribed to this computer template that you had to mouse every little bit of the patient encounter. And what is was, was a desk with a glass table top and I was raking my ulnar nerve over and over again. I never thought after 20 years of education I would have the sort of job where I would have a repetitive motion injury. But I was there being evaluated for it while as I watched this being signed into law. And the thing is that everyone’s just really up in arms about this thinking that this is going to do new and horrible things and it’s not.

Here’s what it does: is it just takes everything that horrible about our current system and mandates that you buy into it, even if you object. And the scariest thing about the latest court case is, the first time in American history someone can tax you for something you did not do. You’re not being taxed for taking an action you’re not being taxed for producing something or selling something. Or bartering any sort of transaction. You’re being taxed for an inaction.

So this includes all the negative elements of what brought us here. But the other thing it does- it shuts off any escape valve for cost shifting. Everyone’s co-opted into this thing. So what’s going to happen now is once these price controls are enacted and they cannot be dissipated by cost shifting , you’re going to have massive shortages. It’s going to be really hard to get in to see anyone or get care. So if you get sick, expect to be deflected to the ER when you go to your doctor’s office. The doctor’s office is for routine care and simple stuff. You do anything that screws up the flow of the schedule, they’re going to punch you to the ER. When you get to the ER, expect long waits because everything’s being shunted there. And EMTALA remains in effect. Call your doctor’s office. Go out in the hall; call your doctor’s office on the cell phone. (They) will say, “If you think this is an emergency call 911 go directly to the emergency department. When you get to the Emergency Department, what’s the thing the triage nurse says to you? “Didn’t you call your doctor” No one wants you. Because you are a liability to everyone involved in this system now.

If you need admission, it’s going to be a fight. We’re going to have to find a damn good reason for you to get in and we’re going to have to ram a square peg into a round hole to make sure we get some sort or reimbursement and you’ll be kicked out as soon as possible whether you’re ready or not. It’s all protocol-driven. Any time you receive a treatment it will be per protocol. If you come in chest pains, you’re going to be discharged on a statin. And if you’re not discharged on a statin, that’s going to create the physician being flagged as an outlier and a troublemaker.

The sicker you are the more you’re viewed as a liability. Be prepared to be discharged prematurely. Come in with pneumonia, you’re not completely better, but maybe good enough, they’ll send you home and right now we’re experiencing multiple ambulance u-turns. And what I mean by that is almost every single shift I work I will see at least one ambulance patient that was someone that was discharged from a hospital being driven home in an ambulance that has to do a U-turn and come back because they are decompensating. Guess what? If you’re at risk of re-admission within 48 hours, they ain’t paying. So now the re-admission is even more of a fight than the original admission because no matter what you do, no one’s getting paid. But lots of people are doing the U-turn because of the premature discharges. And understand this is not because the doctors aren’t good. These are extraordinarily smart and well-meaning people. They’re just operating under the constraints of enormous pressures.

So remember, he who holds the gold makes the rules. What becomes protocol is subject to lobbying groups. And what treatments are approved are influenced by Big Pharma. Big Agri is subsidized corn and you end up “needing” Lipitor and “needing” Glucovance. And what lands most people in the hospital is the dietary habits that are created by a Big Agri and the USDA. And you get admitted into the hospital what they bring to feed you will be what the USDA says to feed you.

So remember getting sick – it’s always meant a loss of control but now it means a loss of control and a loss of your liberty. Your doctor no longer serves you. He serves the collective. His compliance is strongly coerced if not forced. Currently it is coerced very strongly. Soon it will be forced. And remember you are a financial loss to everyone involved. It’s cheaper if you die. As long the protocol was followed it’s in your best interest to be a quick healer. That’s why you want to eat the Paleo diet. That’s why you want to do high intensity exercise. That’s why everything that we talk about here is so important. You do not want to get in the belly of this beast.

So, you doubt me? Take the airport test. When you guys are flying back home, look around. The vast majority of people are already within the belly of the beast. And that’s the thing that always cracks me up when you hear, you know, fitness guys that get up here and say, “I’m going to change the healthcare system. We’re going to be more about prevention and health than we are about disease.” Come to work with me one day.

You. Have. No. Idea. How sick people are.

I saw a 48-pound two year old with Type 2 diabetes. At Walmart you can buy nipples that screw on to a Mountain Dew Bottle. Look around you. Just walk out front look at someone out in the smoking area that’s you know, a hundred pounds over-fat. And realize- this person gets the flu? They’re going to be real sick. The onslaught of sick people that need big Pharma-type interventions because it’s all predicated and focused on that sort of recovery from the brink. There is so much of that coming at you so fast you don’t have any time to think of alternative medicine or prevention or anything like that. Doctors are buried by this. So being fit and medication free gives you an enormous competitive advantage and it subverts dependency. Direct control over your life is removed. It leaves you in a much more resourceful mode of being able to deal with the multiple indirect controls that are being exerted over you right now.

So how do you do it? Eat a Paleo diet.

And you don’t have to eat Paleo.

What that means is “avoid Neolithic agents of disease”. Eat nutrient dense whole foods. Single-ingredient diet. You should eat something that has a single ingredient: Broccoli. Meat. Eggs. I was talking to Dave earlier and we were talking about eggs, fat and the diet and how important it was and particularly how important it is in pregnancy and gestation. Dave said, “Look at an egg. Look at a yolk. Everything you need to make a chicken is right there.” That’s nutrient density. Eat a Paleo diet. Find a book: Primal Blueprint {by Mark Sisson}. Rob Wolf’s book, The Paleo Solution. The ONE diet by Simon Shawcross who spoke in London. Primal Body Primal Mind by Nora Gedgaudas and The New Evolution Diet by Art Devany. Pick any one that appeals to you and follow it. If you respond better to visual and aural presentation, see my 21 Convention Talk on Youtube 2010. I’ll lay it all out for you in technical detail so you’ll understand both the ‘why’ and the ‘how’.

Exercise. Do high intensity, low force exercise with plenty of recovery. What Skyler told you is gospel truth. You can read my book “Body by Science”.

“First, do no harm.”

{~Hippocrates}

Find Bill DeSimone’s work and read it. Moment Arm Exercise. You don’t want to injure yourself either. It’s not enough not to be sick. You tear your rotator cuff. Guess what? You’re in the belly of the beast. So you should avoid ballistic exercise and if they use skill based movements in a fatiguing protocol. I love the spirit of Crossfit. I love the notion of: doing-hard-things-builds-character. But what I don’t love is a fatiguing protocol with skill-based movements that are going to get you injured. Same thing with P90X or Insanity workouts. Do high intensity, low force workouts. Because injury will put you into the belly of the beast very quickly. Remember, when you’re becoming super-human, the way to do that is to remember you’re only human. And biohacking -everyone referred to it as cheating. It’s not. It’s not cheating. You’re not cheating anything.

Francis Bacon said it best: “Nature, to be Commanded, Must Be Obeyed”.

You’re obeying nature when you’re following a Paleo diet, when you’re doing what Dave Asprey tells you when you’re doing what Skyler Tanner tells you, you’re being a good animal. A cheetah doesn’t have to count his calories. A lion doesn’t count his calories. They’re in perfect metabolic and physical conditioning without even thinking about it. The same is true for us. The reason it seems like such hard work is we’ve become so far removed from the evolutionary dictates that made us what we were meant to be.

The other thing you want to do is what I call Black Swan Avoidance. Or my dirty dozen plus one. So let’s talk about them.

~~Break transcript~~

Doug humorously reviews a bunch of ways he has seen people die as an emergency room doctor and suggests ways to not get yourself into those situations. I’m not going to transcribe it at this time. But a couple of key quotes/paraphrases are:

“Force is Mass Times Acceleration. Take it from an Emergency room doctor”

“If the grill won’t light, walk away”

“The ladder. This is the white man’s scourge”

“Buy your home to retire in. Don’t build it. I see guys die of a myocardial infarction from arguing with a contractor once a week. We live in a resort area so there may be selection bias.”

“If you ever get into a car at the point of a weapon, you will most certainly die but not until you have really, really suffered.”

“Be Kind. It’s the most important thing for your health and our society.”

“Speaking of kindness-We have these huge forebrains. It’s very important for communication. And it’s what’s lacking when you communicate of the then interact or over the cell phone or by text messaging. There’s a very strange version of stroke called Aboulia, when you have a stroke in the frontal lobe of your brain. I can walk up and talk to the patient and speak to them and they just stare at me with this dead-pan face. And their answer doesn’t come out until 10 -15 minutes after I ask the question. But I can give them a cell phone and call them, step outside of the room and get a complete history from them because they’re communicating in a mechanism that is not at all facial recognition in the pre-frontal lobes of the brain. Realize that when you are communicating over the internet and you are flaming someone on the internet and you’re getting into these little pissing matches that you are not engaging your frontal lobes. You are saying things that you would never say to someone’s because you know damn well you’re likely to get punched or killed. Kindness matters. Because we all must die.”

“I’ll leave you with the words of Ron Harris who wrote The End of Faith and he said this: ‘Consider it. Every person you have ever met. Every person you will ever pass in the street today is going to die. Living long enough each of us will suffer the loss of friends and family. All are going to lose everything they love in this world. Why would we want to be anything but kind in the mean time?’”

and

“Stay Out of the Belly of the Beast”.

Doug then takes some questions and tackles subjects such as:

Walmart and it being the logical consequence of the removal or market forces (i.e. You can buy donuts right next to antacids and diabetes medication)

Sexuality and sexual health

Recommendations for health insurance (already out of date)

More details on the bureaucratic Armageddon of Obamacare

Why do other countries with socialized medicine look so cool and we don’t?